NAM is the official provider of online scientific reporting for the
8th International AIDS Society Conference on HIV Pathogenesis, Treatment
and Prevention (IAS 2015), which will take place in Vancouver, Canada,
19th-22nd July 2015.

With
proper training and supervision task shifting of medical male circumcision to
non-physician clinicians in Africa can be done
safely, according to researchers in South Africa and North America reporting in
the advance online edition of AIDS.

This
systematic review and analysis of ten studies (from South Africa, Kenya,
Comoros, Nigeria, Zambian and Uganda) with information on over 25,000
circumcisions done by trained non-physician clinicians (nurses, midwives,
surgical aides and clinical officers) found adverse events were not serious;
and the pooled relative risk in two studies separately reporting outcomes for
doctors and non-physicians showed comparable rates of adverse events (1.18: 95%
CI: 0.78-1.78).

Evidence
from randomised trials and observational studies support the protective effect
of male circumcision for men getting HIV. Widespread male circumcision in Africa could prevent up to six million new infections and
three million deaths in the next twenty years according to mathematical
modelling estimates, note the authors.

In
addition to ethical and acceptability challenges a severe shortage of health
care workers in high prevalence countries, notably in Eastern and Southern Africa, is one of the major obstacles to
effective scale-up.

Task
shifting, the planned delegation of tasks from specialists or doctors to non-physician
health care professionals, is a proposed strategy supported by WHO to increase
scale-up of HIV treatment and prevention services. Randomised trials have
provided evidence of the safety and efficacy of task shifting for ART.

To
date evidence of the safety of circumcision by non-physician health care
workers has been mixed. Reports of high rates of serious complications, note
the authors, have confused those circumcisions undertaken by lay people with
little or no training, lack of supervision or supportive equipment with
circumcisions undertaken as a result of task shifting.

While
there have been systematic reviews looking at the frequency of adverse events
after circumcision, none have specifically looked at task shifting, note the
authors.

The
authors undertook a search of online databases and conference websites up to
July 2011 reporting the outcomes of task shifting for circumcision in Africa.

Task
shifting was clearly defined as “the planned delegation of the surgical act of
male medical circumcision to non-physician clinicians (that is any health
workers below the level of doctor).” All unplanned studies (those without
training and/or supervision) were excluded. Studies with teams of providers
were included as long as more than 70% of the team were non-physician
clinicians.

Out
of 1,885 citations first identified 33 studies were evaluated and a final ten were
included in the analysis, of which six were undertaken in health care settings
and four in the community. Two studies described a task-sharing model in which
a doctor was part of the team; eight reported on outcomes in adults and two on
outcomes in children.

The
proportion of adverse events ranged from 0.70% (95% CI:0.44-1.02%) to 37.36%
(95% CI:27.54-47.72%) with an overall pooled proportion of 2.31% (95%
CI:1.46-3.16%). A high level of heterogeneity was expected. Using an
alternative means of confidence interval estimation did not change the
proportion (2.33; 95% CI:1.44-3.20).

No
differences in the frequency of adverse events were seen when comparing adults
and children; or between task shifting and task-sharing models; or when
circumcisions were done in the community compared to the health care setting.

Among
the six studies reporting on specific complications excessive bleeding ranged
from 0.30-24.71% with an overall pooled prevalence of 0.55% (95% CI:
0.13-0.97%); and infection was seen in 0.30-1.85% of cases with an overall
pooled proportion of 0.88% (95% CO:0.29-1.47%).

The
authors note their findings are comparable to male medical circumcisions
undertaken by doctors, urologists and surgeons and cite a systematic review
that found the frequency of severe adverse events ranged from 0 to 25% in
children and 0 to 33% in adolescents and adults.

Additionally
they cite a report from Israel
of over 19,000 circumcisions done mostly by trained ritual circumcisers with an
adverse event rate of 0.34%.

The
authors suggest some of the studies may have underestimated the number of
adverse events if only immediate issues were reported. Infection can take a few
days and sexual function problems take longer to determine.

While
the authors included a broad search category they were aware of much
unpublished data from routine programmes where circumcision is part of HIV
prevention. Data was not disaggregated by provider so could not be included.

Critical
to the safety of male medical circumcision is the quality of training and
supervision, availability of safe equipment and the number of circumcisions
performed, the authors stress. They cite a Ugandan study that showed the
post-training rate of adverse events after circumcisions done by physicians
went from 8.8% for the first 20 procedures to 2% after 100 procedures. One
study in this review similarly reported complication rates at 3.8% for the
first 100 procedures falling to 0.7% after 400 procedures.

Areas
for further research, according to the authors, include reporting of all factors contributing to safety including:

Length and duration of training

Provision and use of supportive materials

Relative contribution
of team members where a skills mix is used

Frequency of adverse events depending on the experience of
the practitioner

Standardised approach to the reporting of adverse events.

The authors note that as an HIV prevention intervention
circumcision has been found to be cost-effective. However, what is also needed
is the assessment of the potential cost savings of task shifting.

Charging
for services has led some to turn to informal providers with adverse results.

The
authors conclude their “review provides reassurance that task shifting of male
medical circumcision to non-physician clinicians can be done safely, with
reported rates of adverse events similar to doctors and specialists.”

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